Menopause Expert: Belly Fat Grows During Menopause! Your Estrogen Levels Are Controlling You & This Hormone Is Quietly Killing Your Sex Life!

Three to 75% of women do not get the treatment for perimenopause and menopause that they deserve. And women are asking, why is it that I can't manage stress the way I once did? Why do I have this belly fat that appeared out of nowhere? And my usual techniques for how to deal with that aren't working.
Why would I rather mop the floor than have sex with my husband? But there's more than 100 plus symptoms that women aren't aware of. But you believe many of the symptoms of menopause are avoidable? Yes.
And let's get into that. Dr.
Sarah Sal is the Harvard-trained physician and hormone expert who's unlocking the science and simple tricks behind feeling your best, no matter your age. Most people have imbalanced hormones.
Think of them as text messages that your body sends to keep everything functioning optimally. But for example, out of the 40,000 people I've tested and treated, around 90% of them have a problem with their cortisol hormones.
And if my body's making too much cortisol, what is the harm? It's associated with more belly fat. We know that it shrinks the brain in women, but not men.
It's associated with depression, but also if you're someone who's making a lot of cortisol, you're going to make less testosterone. And that leads to a whole host of serious problems.

And what about trauma? Does that impact your hormones?

Oh, yes. And one of the ways to measure trauma is the ACE test.
It's a validated questionnaire.

And they found that people who had one or higher ACE scores had a greater risk of 45 different

chronic diseases. And my score is six out of 10.
But those ACEs are living on in your body.

And you went on a journey to heal yourself. Yes, with lifestyle medicine, not a pharmaceutical.
Tell me about that journey. I find it incredibly fascinating that when we look at the back end of Spotify and Apple and our audio channels, the majority of people that watch this podcast haven't yet hit the follow button or the subscribe button, wherever you're listening to this.
like to make a deal with you if you could do me a huge favor and hit that subscribe button i will work tirelessly from now until forever to make the show better and better and better and better i can't tell you how much it helps when you hit that subscribe button the show gets bigger which means we can expand the production bring in all the guests you want to see and continue to doing this thing we love if you could do me that small favor and hit the follow button wherever you're listening to this that would mean the world to me that is the only favor i will ever ask you thank you so much for your time dr sarah zahl what is it that you do for people i'm a physician so i work in academic do research for people, I teach, and I take care of patients. So that's the official BBC answer.
And the unofficial answer is, I'm a healer. And what does that mean, a healer? Because that's a broad term, so that could mean many things.
It means that my task is to connect to your innate healing capacity and to work with you to activate it.

And who do you do that for?

So I do it for professional athletes, executives, and everyday people.

And when you say healing, if someone came to you and they said, how do you heal people? What would your answer be? My answer is I don't heal people. That's a, to me, that's a patriarchal way of thinking about it.
What I do is I work with someone who's got the capacity to heal. And we work to be in the service of that.
So it's not me providing something that they don't have already. It's more understanding what some of the obstacles might be to their own healing.
Understanding what would allow them to be the best version of themselves, to feel fully alive.

And what was your training? So can you talk me through your sort of academic journey? Sure. So my training is as a bioengineer.
I did the Harvard-MIT program, which is designed to train physician scientists.

So the ethos of this particular program was to train the future researchers and academic physicians so that we could move the field forward. And all along, I was really interested in how do you bring the best of conventional medicine together with more ancient ways of thinking about the body? Things like Ayurveda from India or traditional Chinese medicine.
How do we take these wisdom traditions and use that to inform mainstream medicine? So that's the type of care that I learned how to do. I became a surgeon.
I did primary care after I finished a residency in obstetrics and gynecology, but I also realized pretty early on that I wanted to take care of men too. So I've done that for about the past 15 years.
And I would say that training in bioengineering and a comfort with big data and with optimizing data sets to improve whatever the goal is, like performance or having the best conversations you can have on a podcast, that's what gets me excited. How many people do you think you've treated or seen or worked with directly in your career? Probably about 40,000.
And if you had to try and summarize maybe the top three or five things that you're doing for them, what would you say? Well, number one would be hormones. Hormones are the portal that most people start with me.
It's a way of thinking about what drives what you're interested in. Most people have imbalanced hormones.
I haven't detected that you do yet.

But most people have an issue, say, with cortisol, either making too much of it or too little or even both within the same day.

And it affects energy.

It affects mitochondria.

So I would say the number one thing I help people with is their hormones,

getting their hormones back into balance, starting first with lifestyle medicine, not a pharmaceutical. So that includes breath work, which I think is one of the most underutilized tools that we have in health.
Number two would be nutrition. but taken to the next level not what you might think of that a nutritionist would advise you but

what nutrition. But taken to the next level, not what you might think of that a nutritionist would advise

you, but what specifically is the ideal food plan for you, for your goals? So whether you're a

entrepreneur and podcaster and investor, or you're a professional basketball player,

or you're a woman in perimenopause at age 42,

what's the optimal nutrition for you? And we can measure that. And we can look at the interaction of your genetics together with what you're eating to see how we could personalize that.
Number three, I would say, is prevention. And prevention has been a hard thing to sell.
It's, you know, a lot of people just don't want to invest in prevention. And yet, I take care of people who are in this continuum from a state of health, often to a state of pre-disease, like pre-diabetes as an example.
And if they don't do something about it, they then move on to diabetes. So I like to intervene there as early as possible to reverse disease.
And most of that is lifestyle. So those are the things that I tend to work with.
I do a lot of metabolic health because it's so critical for the energy that you feel each day. You have a very diverse experience as a doctor slash healer.
It feels like you've really had a lot of sort of reference points in your career that you've drawn upon. And ultimately, you became the director of precision medicine at the Marcus Institute in Philadelphia? That's correct.
Precision medicine, that term. How does that differ from conventional medicine? It's quite different.

So conventional, mainstream, modern medicine, I believe is broken. I feel like there are so many people who are failed by our current medical system, especially people with chronic disease, things like diabetes, autoimmune disease.
So with mainstream medicine, generally what happens is that you develop a condition, say a high cholesterol, and you get treated with a pharmaceutical, say a statin. And what we know is that we have to treat about 100 to 200 people for one person to benefit.
So that I would define as imprecision medicine.

Whereas precision medicine is where we understand you as an individual. We look at your genomic blueprint.
We look at your biomarkers. We look at your wearables data to determine NF1 experiments where you serve as your own control and figure out what's going to be the most effective for you, depending on what your goals are.
And if one, you mean where that individual is the study, they are the experiment. That's correct.
You're not looking at broad sample sizes. What is wrong with conventional medicine? You use the term that it's broken.
What is wrong about that approach? There's a few things that are wrong. One is that

it has become medicine for the average. And when you look at scientific evidence and you rank order it, what's considered the highest form of evidence is the randomized trial.
But the randomized trial is mostly around using a pharmaceutical.

So in the example I just gave, using a statin to help someone with their cholesterol, maybe help prevent a heart attack, the number one killer. The problem is we then, based on randomized trials, come up with medicine for the average.
And it's not about optimal health. It's not even centered around health.
It's centered around, okay, heart disease is number one killer. How do we help people prevent it? Oh, lifestyle medicine prevents 70% of it? Well, we're not going to do that because we can't make money off of it.
There's no profit motive. So we're going to focus instead on these pharmaceuticals.
Oh, GLP-1s. That sounds like a good idea.
Let's try that and solve problems with GLP-1s. So to me, there's many layers to why the healthcare system is broken.
But one key area is that 70% of the diseases we're facing right now

are utterly preventable with lifestyle medicine.

70%.

You used the word hormone balance earlier on,

and you said that that's the portal in which people often find you.

I really don't know much about hormones,

and it's not necessarily something that the average person thinks that they can do much about, I think. Because it's not easy to measure our hormones, is it? Well, you can measure it in the blood.
So it's not that hard to measure hormones. But I think there's a way that in mainstream medicine we're taught to tell people that their hormones vary too much.
And so it's not worth measuring. Yeah, that's what I've heard before.
It's what you've heard, but then if you're a woman who's 34 and you're trying to get pregnant and you're having trouble, in that situation, we'll measure every single hormone. We'll look at thyroid, cortisol, testosterone, estrogen, progesterone, the control hormones like follicle stimulating hormone.
And yet somehow in that situation, testing is more reliable, but it's not in this other situation. That doesn't make sense.
That's double standard. Why did you choose this career? What is it about you, your childhood, your life that sent you down this road? I would say it was growing up with a fair amount of trauma.
And, you know, what I've learned about trauma is it's less about what actually happened to you. It's the way that it became embedded in the system of your body.
So for me, my parents got divorced when I was really young. I grew up in a way that I became a helper.
And I realized that by being someone who was really looking out for others and tuning into their energy and helping them achieve their goals, that kept me really safe. And so there's a way that that, it was very resonant for me to discover medicine.
And one of the things we know about people who go into medicine is that people tend to have a fair amount of trauma that leads to becoming a helper in this way. What was that trauma? So there's a lot of different ways to measure trauma.
One of the ways that I find helpful is something called the adverse childhood experiences. So ACE for short.
I think I've got it here. Oh, do you? It's a questionnaire.
So my score is six out of 10. So childhood divorce, my parents got divorced when I was about a year old.
That's one out of the six. Other things are abuse, neglect, emotional abuse, physical abuse, having a parent with a substance use disorder.
So things that, you know, it's not a complete list, but it's a validated questionnaire that was used in the 1990s and found among people who are middle-aged, you're not quite yet middle-aged, but for people who are middle-aged, 40 to 65, they found that people who had higher ACE scores, one or higher, they then had a greater risk of 45 different chronic diseases. How important is it for us to understand our early upbringing and our trauma if we are to heal as adults? Because you said there that if you score high on this ACE score, this trauma score, this childhood trauma system sort of questionnaire, then as an adult you're more likely to get a variety of different diseases.
So do we need to heal our bodies in some way to avoid getting some of those diseases? Yes. And that's the critical question.
So if you know that you have an elevated ACE score, and there's a lot of people who have a score of zero, about 40% of men, about 30% of women. And what we know is that if you've got this greater risk for 45 different chronic conditions, there's a way that those ACEs are living on in your body unless you're addressing them.
And it's the living on in your body that we want to pay attention to. So for some people, it's their immune system, and it leads to more allergies, more histamine overload, more food intolerances, maybe autoimmunity, where their immune system is attacking their own tissues, maybe autoimmune disease.
Are there people who have more nervous system dysregulation? Maybe they've got anxiety or depression or post-traumatic stress disorder, mental health issues. And for other people, it could be more endocrine.
They've got chronic cortisol problems. Which is hormones.
Yes. How did that manifest in your physical health? So I didn't start to detect this until my 30s.
But what I found was that I had depression. I had premenstrual syndrome.
I had my first baby when I was 32 and I couldn't lose the baby weight. And as all of this was happening, and I'm a physician, I went to my doctor for help.
And he suggested that I go on Prozac for the depression and the mood issues. Which is an antidepressant pill.
A selective serotonin reuptake inhibitor. That I go on the birth control pill because I sounded hormonal, and that I start exercising more and eating less.
So that was his treatment, and that's typical mainstream medicine treatment. But I wasn't satisfied with that.
I felt like that doesn't seem right. And I left his office and went to the lab, ordered my own hormone panel, and found that my cortisol was three times what it should have been.
So there's the optimal range for cortisol in the blood. It's about 10 to 15 in the morning, 6 to 10 in the afternoon.
And mine was 30. I also looked at my fasting glucose and insulin, and I had prediabetes in my 30s.
I had no idea. No one was checking for this.
So I'm answering your question about how these ACEs showed up in my body. We know that adverse childhood experiences link to blood sugar problems and a greater risk of prediabetes and diabetes, which I had.
We know that they link to chronic stress and cortisol problems, high perceived stress, whether the stress is there or not. It also led to, as I started using wearables, low heart rate variability, the time between each of my heart beats.
And that's a measure of the sympathetic nervous system, fight fight, flight, freeze, spawn, versus the parasympathetic nervous system, which is where healing occurs. And you went on a journey to heal yourself.
Yes. Tell me about that journey.
So in my 30s, this was a huge epiphany for me because I realized that I wasn't trained. I wasn't educated.
Even though I had an outstanding education, I wasn't trained to help with this. No one taught me about cortisol problems and how to manage that.
I mean, I was taught about the extremes of Cushing's disease, which is really high cortisol levels, and Addison's disease, which JFK had. And it's when your adrenals in your back above your kidneys don't make cortisol.
So I was taught about the extremes, but I wasn't taught about all the people who kind of live in the middle with problems with their cortisol.

So this is when I started to take the scientific literature and apply it to my situation because I wanted to feel better. I felt old before my time, and I had a lot of belly fat, and I was on this path of aging at an accelerated clip.
So I did it to help myself, but then I also wanted to help my patients. And it felt like I needed to go deeper and understand what can we do to treat the trauma and also to treat the more proximal measurements that we're making, like with cortisol, with heart rate variability, with blood sugar.
So what was step one for you? Step one was awareness. Okay.
And I had no idea. These are not things that most doctors are checking for.
It's pretty crazy that you're a doctor, but you don't know this part of health. I mean, how are you going to help anybody if you don't fully understand health from a more sort of holistic perspective? That's a critical point.
So I was taught at Harvard that if you have blood sugar problems, if you've got prediabetes and diabetes, the treatment is lifestyle. It's the most effective to change the food that you're eating, to increase your exercise, to manage your stress in a different way.
And yet I wasn't taught how to help my patients do any of those things. I was taught how to prescribe a medication for it, like metformin or some other treatment.
But I wasn't taught how to do lifestyle medicine. I had 30 minutes on nutrition.
So yes, it is pretty crazy. They gave you 30 minutes on nutrition? Yes.
During which training? This is medical school. And I got about the same amount on perimenopause and menopause.
Really? I mean, that explains a lot. Yes, it does.
About the medical system. So step one was awareness.
What was step two? Step two was, what does the science tell us? And if we take what the science tells us, usually applied to a population, that then sets us up for step three, which is end of one experiments. Trying things on yourself and then measuring.
That's right. When we think of cortisol, which was the first sort of marker that you saw was elevated, we think of stress.
So we think we get cortisol if we're stressed. So my brain, my very naive brain said, well, you just need to be less stressed, Sarah.
So you should just go on a holiday and then your cortisol will come down. I used to think that too.
And then I would come back from the holiday and I would still have cortisol problems. So stress is part of it, but cortisol is really interesting.
These hormones that we're talking about, estrogen, progesterone, testosterone, cortisol, insulin, it's not a democracy. Like, they don't have equal footing.
Cortisol is more like a dictator, especially if it's out of whack. So you need cortisol to live, whereas you could live without testosterone, estrogen, progesterone.
Can't live without insulin. But cortisol is critical in terms of helping you with your immune system, helping you with your blood sugar, and just managing the stress response.
So it's not quite as simple as thinking your way out of a high cortisol or a low cortisol. And there are ways that your body can become stuck in a particular pattern of making too much cortisol or making not enough cortisol.
And if my body's making too much cortisol and my levels are too high, what is the harm? The harm is it's associated with depression. It's about 50% of people with high cortisol.
50% of people with depression have high cortisol. It's used by some psychiatrists as a suicide marker.
It's associated with more belly fat. And so the fat receptors, the fat cells in your belly have increased receptors for cortisol.
So it's a way of growing your belly fat. We know that it shrinks the brain in women, but not men.
Starting in midlife, starting in your 40s, it's not an old age thing. And this has been shown a couple of different ways.
There was a study from the University of Texas in San Antonio showing that women in their 40s with high cortisol have a shrinkage of total brain volume. And then Lisa Moscone at Cornell also just showed in a study looking at men and women that women with high cortisol also have shrinkage of their total brain volume.
And they start to have a difficult time using glucose as fuel in their brain. Which is going to result in what kind of behaviors? Well, it makes you tired.
It gives you slow brain energy. And I can tell for the most part, you don't have that.
But if you do have it, there's a way that you kind of, your brain slows down, you feel foggy, you're not able to multitask and kind of keep up with everything. Is there a link between cortisol and trauma? Oh, yes.
What is that link? So for people who experience toxic stress or trauma, what typically happens is cortisol goes up.

That's part of the alarm, the body's stress response.

What we know is that for people who've got more serious exposure to trauma and they have post-traumatic stress disorder,

those people have probably gone through a period of high cortisol and now they can't keep up anymore. And they are in a low cortisol state.
What are the things in the world at the moment that are messing up our hormones? Because the subject matter of hormones has become increasingly popular. And I know that there's hormones like cortisol, which we've talked about, testosterone, estrogen, progesterone, insulin, glucose.
What are the big things that are like messing up our hormones at the moment? Because I want to make sure my hormones are in check. So I'm a guy, and I'm sure that there's, you know, some of these hormones are more, like things like estrogen have, I think, more pertinent to women.

No, it's important for men too.

Oh, really?

So estrogen and progesterone are incredibly important for men.

And it's, you know, it's involved in bone strength, progesterone's involved in sleep in men.

So the levels are lower in men and your testosterone is about 10 times higher.

But in women and men, they're all important. So what's messing with our hormones? I would say toxin exposure.
So there's endocrine disruptors. There's more than 700 known endocrine disruptors.
things like bisphenol A, like the plastic lining that you see in cans or in plastic containers, water containers. There's skincare products, which women are exposed to more, things like moisturizer and makeup and other things that contain um endocrine disruptors like parabens.

And there's flame retardants that we get exposed to. So there's a whole class of endocrine disruptors.
And then it feels right now like we are more dysregulated than I've ever seen. and I'm not sure what the cause is.

I don't know if it's the post-pandemic experience or part of what we're experiencing in the United States with the change in leadership. It just feels like there's this hum of dysregulation that I haven't seen over my career.
Are you noticing that? Are you seeing that in your patients? I see it in my patients. I see it in their wearable data.
I see it in heart rate variability. I see it in the cortisol levels that I'm measuring.
You asked if I'm noticing that. I mean, the more digital the world has become, I think I've seen more dysregulation.
And we're obviously moving further in that direction at rapid speed, especially with things like AI now and algorithms getting more smart and addictive. Yes.
So I see that. Also, there's just been a change in...
I think the algorithms, the social media algorithms will compete with themselves to see who can hold you the most. And to do that, they have to kind of grab your attention.
And the easiest ways to grab your attention is by showing you things that are probably dysregulating. Yes.
It's an attention economy. And the cost in that fight for attention is that often the nervous system becomes more dysregulated.
So if you had to come into my life and you had to optimize my life to make sure that all my hormones were in check, you would get rid of plastics and toxins from my everyday life, my bathroom, et cetera. I'd look at your skincare.
I'd look at your cleaning products. I'd look at your air quality.
I'd probably install a couple of air filters if you don't have that. I'd want to know about your stress because you're someone who performs at such a high level.
And I would assume that you found the right level of stress where it's not so little that you're not productive, but it's not to excess to the point that there's a cost to it physiologically. Yeah.
And then? And I'd want to look at your food. I'd want to know how much protein you're consuming.
Are you getting the right amount of carbohydrates? Seems like you are. Are you utilizing those well? What's going on with the continuous glucose monitor? How are your nutrients? What's your vitamin D? Things like that.
You're a big fan of continuous glucose monitors, aren't you? I am. I think it gives real-time feedback, immediate feedback on the food that you're eating.
I've seen nothing else change behavior like a continuous glucose monitor. And for anybody that doesn't know, it's the little patch you put on your arm and it tells you your blood sugar levels in real time, straight to your phone.
Sugar. Is sugar the enemy? I don't think sugar is the enemy.
I think the The enemy is the way that we eat it to excess, the way that we use it to change our emotional

state. And we know people who have adverse childhood experiences, they're more likely to have disordered eating.
They're more likely to have problems modulating the amount of sugar they consume. When you're treating patients, do you focus heavily on their blood sugar levels? I do, because I think it's an important indicator of the way the biochemistry of the body, the metabolism is working.
It tells me about their mitochondria. It tells me about the way that they're producing energy, ATP by ATP, this compound, this measure of energy that you produce inside of all of your cells.
Which is called ATP? ATP. And that ATP then drives what? It drives everything we do? ATP is fuel.
So it allows you to feel like you're fully energized, especially when you wake up in the morning. And are there any supplements that I should be taking if I'm trying to optimize my hormonal balance? Well, I'd have to look at your total picture, but most of us inherit somewhere around five to seven genomic vulnerabilities.
And often we want to work around those. So for instance, for me, my vitamin D receptor sucks.
It just doesn't work very well. So I have to take increased levels of vitamin D to keep the kind of the baseline amount of vitamin D in my system normal.
So we would want to look for those. We'd look at your genomics to see what's your relationship to B vitamins.
With the stress that you manage, do you have a deficit with B vitamins? For a lot of men, it doesn't show up until around age 40. So this is a good time for you to do a baseline.
When you look at people's biomarkers and their blood samples, what are the things that you like typically always see that are deficient? Because I'm sure there's things from a social level that we're just all kind of getting wrong. Vitamin D is common.
So somewhere around 70 to 80% of people don't have enough vitamin D. And one of the things that I think is so important to realize about vitamin D is that it's got 400 jobs in the body.
One of them is keeping your boundary in your gut intact. So keeping tight junctions working so that you don't have leaky gut.
So vitamin D is a common one. I had an executive that I took care

of on Tuesday, and he had a fasting glucose of 102, which is in the prediabetes range. No doctor has pointed this out to him before.
He had, his cholesterol was starting to climb. His blood pressure was borderline.

Not high enough to require a medication, but at the point where we want to turn that chip around before he needs a medication. He had a level of inflammation in his body that was causing aches and pains and kind of like this silent condition that wasn't working well for him.

So there's a couple of ways to measure that.

For him, his homocysteine was elevated.

It was 14.7.

And that's one that's really easy to measure in a basic panel.

What we want with homocysteine, which is heart-specific inflammation, we want that to be 5 to 7. And when it's elevated, that tells us that often part of the biochemistry in the body, your methylation, is not working well.
Methylation is just where you add a carbon and three hydrogens to a molecule. And it's a way that we turn genes on and off.

And so in this person's case,

he wasn't getting enough B vitamins,

methylated B vitamins.

So we started him on a supplement to help him with that.

So that's a common one.

His testosterone was good.

So didn't have to address that.

This guy was about 52. His testosterone was good.
So didn't have to address that. This guy was about 52.
His cortisol was good. He was the chief financial officer of a company back east.
Well, he had a number of things on his genomics that we needed to pay attention to. What was interesting about this guy, Steve, is that he was an athlete.
He played football in high school and college. He had this identity as an athlete.
But when he came to see me at age 52, he was barely exercising. He would lift weights maybe once a week.
He would go swimming for about 30 minutes once a week. And so he wasn't leveraging disposal of glucose the way that he could be, the way that he used to when he was in his 20s.

So a big part of understanding what made him tick was to reaffirm this identity as an athlete and to use that to address this metabolic crisis that was starting to happen in his body before it was too late. Because he's got too much glucose and he's not doing enough with it.
That's right. So his body is having to store it and getting inflamed.
And he said, you know, listen, it's been the Christmas holidays. I had a lot of pound cake.
I had some cocktails. You know, maybe that's part of the problem.
But we had measured his hemoglobin A1C, which is a three-month summary of what's happening with your glucoses. And the problem predated Christmas.
So we needed to get him into action around exercise. Getting back to hormones, I really want to close off on this subject of cortisol because I know that that's such a important hormone.
I've heard you say before that you believe that cortisol is the most critical hormone to get into balance. You want to focus on cortisol really first and foremost.
So someone like me, is there

anything else I need to know to get my cortisol levels in balance? And also, what percentage of the population do you think have their cortisol out of whack? So we don't have data on the numerator or the denominator. And my patient population is enriched with people who've got cortisol problems.
So out of all of the people I test, somewhere around 90% of them have a problem with their cortisol. And that includes professional athletes, because at least in the U.S., like basketball players, they travel a ton.
They play back-to-back games. They've got a cortisol load, a stress load that is pretty high, even for someone in their 20s or 30s who's used to high performance.
So the number is high. If I had to look at the general population,

it would be a total speculation.

I would say somewhere around 30 to 50%.

And what do you do about that if you're an athlete

and you've got elevated cortisol levels?

I think there's a number of different things.

There's the top-down approach, which is cognitive, kind of like, what is my prefrontal cortex? How can I leverage that to work with this? And then there's more of a bottom-up approach, which is using your senses to create safety and to change the cortisol signal, kind of the alarm in the way that it goes off in the body. So breath work is really important for that.
Meditation, different forms of movement, dancing, you know, rhythmic movements, walking, hiking. Running is a little tricky because that can be a stress response and it can raise cortisol.
So I would say for a professional athlete, what I usually recommend is meditation, regular meditation, and finding what's a really good fit for them. Because, you know, for some people, mindfulness-based stress reduction is a good fit, but that doesn't fit for everyone.
Other people like resonance breathing, like a five-second inhale, seven-second exhale, six breaths per minute, doing that for 10 to 20 minutes. That can really help to create balance between the parasympathetic nervous system and the sympathetic nervous system.

For some of my athletes, it's a supplement. So if they've got high cortisol, one of the things I often do is to give them Cortisol Manager, which is a supplement that includes ashwagandha and phosphatidylserine.
And it's been shown to lower cortisol levels. So if they're traveling and they have to take a plane back to Philadelphia after an away game, cortisol manager can help them manage the cortisol.
I've found a supplement called, I can't pronounce the name properly, but rhodiola? Oh, rhodiola. Rhodiola.
Yes, rhodiola is an adaptogen. So it's an herbal therapy that's been shown to help with cortisol.
Low as cortisol. Yes.
And I was reading that it increases your focus potentially. Yes, it does.
Do you prescribe that to athletes? I do. So generally what I try to do with most of my athletes is have them take a supplement either first thing in the morning or before they go to bed.
It's harder to do it during the day. And so I tend to start with cortisol manager because I think it's got the best data, but rudiola is also a good choice and I have prescribed that.
Is it easy for people to change in this regard to get them to make a set of different decisions? I think we're at a time of year where a lot of people are thinking about changes and a lot of people are failing repetitively every year at the changes they say they want to make. Is it easy to get someone to change? I would say behavior change is the hardest thing that we do as humans.
I think there are ways that adverse childhood experiences tend to set a pattern that's very hard to break. But I see people change their behavior all the time.
And I think part of it depends on what's the pain of staying the same. If it's high enough to motivate you and to help you, you know, not take the shot or two of tequila that has been your downfall in the past, if you have something that keeps you accountable and has like the Hawthorne effect, like a continuous glucose monitor, I think that can also be very helpful.
As if someone was watching you, because my patients with their continuous glucose data, I am watching them. I'm scanning them.
But doesn't that mean that in order to change, some people just need a bit more pain? I would say people have a different level of pain that motivates change. Have you ever seen a situation, we were talking about this a couple of weeks ago,

where when you're trying to help someone, you actually end up propping them up.

And because you're intervening to stop them experiencing the pain that they might otherwise,

you end up harming them because you're preventing them from going to that place where,

you know, they call rock bottom, where self-motivated change would occur? It's a good question. I think there's a fine line between motivating and also speaking your truth about what you're willing to tolerate, say in your partner or friend or family member, and also enabling or being codependent.
And so you have to try to find that line. I mean, one of the things I've found over my career, and it took me a while to learn this, is that if someone has denial about what they're doing and how it's affecting their relationships, their health, their ability to work, say, drinking too much, having a sticky relationship with alcohol, it's not my job to break through their denial.
They have to do that. That's their work.
Now, I can say alcohol has no health benefits. Here's what it does.
Here's what it does to the female brain. Here's what it does to the male brain.
Here's what it does to break the boundary in your gut and cause leaky gut. Here's all of the untoward effects of it.
But it's not my job to break through their denial. They have to do that.
And that's very hard, especially if you have a family member or a friend or a partner who is doing things that are harming themselves. So what do you consider your job to be if you are a friend or a family member? Your job is to determine what your boundaries are, what you're willing to tolerate to stay in relationship.

And that's, you know, that's where interventions play a role.

Where you confront the person and say, I'm really worried about you.

Here's what I'm witnessing.

I really feel like you need to approach this in a different way. Are you willing? But it's a consenting process.
You don't do it for them. What's your experience? Well, I just have so many, you know, because these days I can help people much more than I could 10 years ago, whether it's financially or in other ways.
And so it's often tempting when someone in my life is struggling in some way to just intervene with some kind of crutch. Yes.
And I've actually seen over the last like 15 years that the best things that I've ever done for some of my friends wasn't an intervention. It wasn't paying for for them or taking care of something for them it was being honest with them and then being there as they figured it out themselves and often it was actually removing my crutch which meant that they would fall a little bit and then climb themselves out of the ditch to a very good life so I just always always think about that, that a lot of us through love or through the fact that we can often end up propping people up in our lives,

and we're actually doing them a disservice because we're kind of inhibiting their own natural growth journey. I agree with that.
And I would also say that what you just described is holding a mirror to someone

in a way that is very loving, but also clear.

It's a clean mirror.

And it's very different than just loaning them the money.

Yeah.

And then being there for them as they stumble and struggle

and try to make things different. You talked earlier about the executive that you checked recently.
You said his testosterone levels were intact. Yes.
At what age should I be thinking about my testosterone levels? Or should I be thinking about them all the time? Because I kind of see it as something that I need to worry about when I get a little bit older into my 40s and 50s. It tends not to decline until about age 40, but I would say do a baseline now.
So a baseline biomarker assessment would be worthwhile. And one of the things we found during the pandemic was that the National Basketball Association was playing in a bubble.

They were playing in Florida. And the players cut off from their families and kind of stuck

in Florida for a period of time. They had low testosterone levels.
And these guys normally

have pretty high testosterone levels. So there can be specific situations that can affect your testosterone level.
What was it that was affecting this? Part of it was just being in a hotel, in a bubble, unable to leave, cut off from their community, their family, their friends, their usual ways of blowing off steam. I imagine they didn't measure their cortisol, but I imagine it was probably higher than normal.
And women have testosterone too, but you said, I think earlier, that men just have 10 times more testosterone. Men have more, but it's the most abundant hormone in the female body.
Women are exquisitely sensitive to it. It's the most abundant hormone.

Yes.

Higher concentration than estrogen or progesterone.

About 15 to 17 nanograms in a woman?

That's what I read on WebMD.

Yes, that's a pretty good level. And in men, 300 to 1,000 nanograms?

Yes, I like to see it somewhere around 500 to 1,000.

And what would be a sign that I had low testosterone if I'm a man?

Belly fat.

Gynecomastia.

What's that?

That's when you get breast development.

Okay.

Mood changes, mood swings, irritability, depression, cardiovascular changes, erectile dysfunction, decreased libido. What about in a woman? So if a woman has low testosterone, what are the symptoms we see in a woman? They're similar.
So both sexes have fatigue. That's very common.
Decreased libido. They might

be working out at the gym and not seeing a response. They might have some hair loss.

And testosterone in women has a few unique features. Like one of the things we've seen

looking at MBA students, students who are getting a master's in business administration,

is that the women with higher testosterone tend to be more comfortable with financial risk. I believe it also tracks with confidence and agency.
We have less hard data on that, but those are some of the things that I see. It's a hormone of vitality in both men and women.
So if a woman has low testosterone, she might be less confident, have less motivation, less agency. Less willing to take risks, less sex drive.
What if she has high testosterone levels? Too high. So high testosterone tends to track with polycystic ovary syndrome.
It's the most common hormone imbalance that women have. It leads to infertility.
It leads to increased hair growth in places that you don't want it. So that can include like your chin and between your breasts.
It can lead to insulin resistance in some, but not all, but somewhere around 70% of people with PCOS have insulin resistance. So it leads to symptoms of excess androgen, acne, hirsutism.
It also is associated with problems with the mitochondria. It's also linked to dysregulated stress response.
That's something we see with people with PCOS. So if I'm a man or a woman and I want to get my testosterone levels in order, and I don't want to inject myself with testosterone, are there natural ways, easy ways for me to get my testosterone balanced? It depends on how off it is.
First place to start is your cortisol because cortisol has this interdependent relationship with other hormones.

So if you're someone who's making a lot of cortisol, you're going to make less testosterone.

So someone who's got a high level of stress, like I was talking about the NBA players in the bubble,

maybe their stress was high and their cortisol was high, and that was why their testosterone was lower. So then if I'm a woman with polycystic ovary syndrome and my testosterone is high, doesn't that mean I want to increase my cortisol? No.
In that situation, what we know is that food is probably the most important factor with someone with PCOS. And inside of seven days, by eating a lower carbohydrate diet, you can change your testosterone level.
So you can lower it significantly. Within seven days? Within seven days.
Exercise. I'm currently eating like a ketogenic diet, so my carbohydrate level is extremely low.
Does that mean my testosterone levels are going to be low? Not necessarily, because you're not someone with PCOS. So it's not quite translatable across sex and gender.
But for you, with a ketogenic diet, what we typically see is that insulin levels are lower, so it does seem to help with metabolic health. It can cause some thyroid dysfunction, so it's worth tracking thyroid.
We know that people on a ketogenic diet sometimes have increased inflammation. There are some people who are super responders, and they just do super well with a ketogenic diet.
But some people have about a 10% change in their LDL,

their so-called bad lipoprotein.

So if you stay on it for more than four weeks,

I generally recommend that you look at some biomarkers.

Let's talk about estrogen then,

because I was under the impression that only women had estrogen, but you're telling me that it's an important hormone for men as well. It is.
Why is it so important for both sexes? What does it do? Well, I would say it's more important for women because it regulates the entire female body. So we have estrogen receptors throughout our body.
When women, there's two different life stages where estrogen is low. The first is postpartum.
So if you give birth to a baby, you go from sky high estrogen levels down to almost nothing when you deliver your baby and you deliver your placenta. And so for a lot of women, when they're postpartum, maybe they've got mood issues, they've got fatigue that is more than just the sleep deprivation.
This can be a preview of coming attractions in perimenopause and menopause. So it's a window of opportunity that can tell you about the way estrogen works in your body.
So for the female body, estrogen has hundreds of jobs. It keeps your joints lubricated.
We know that frozen shoulder is a really common diagnosis in women who are in perimenopause and menopause because the estrogen receptors just aren't getting the estrogen. They're not having molecular sex between the estrogen and the estrogen receptor.
So estrogen is really critical in women. It regulates mood, breast development, development of hips.
It's a lubricant for your joints. It's also really critical for your skin.
When estrogen goes down, you make less collagen, and that's why women notice that their skin ages. And in men, it's a little bit different.
The dynamic range is more narrow. And what we generally want with men is for you to have enough estrogen to serve some of these bodily functions, like with keeping your bones strong, but not too much.
Does it have a role in weight distribution in my body? So where are the fat stores and stuff? So in men, I don't know. I don't know the answer to that.
I'll have to look it up and get back to you. But in women, yes, absolutely.
So one of the things that happens for women over the age of 40 is that they typically become insulin resistant. Their cells become numb to insulin.
And what we know is that they gain about five pounds of fat and they lose about five pounds of muscle every decade after age 40. So there's this redistribution of fat, to your point, where they deposit less at their breasts and their hips and their buttocks and more at their abdomen.
Does that happen in men?

I think there's some version of it in men, but I just would have to confirm that. And is that inevitable? No, no, no, you have a choice.
So for women, I think what's important is to understand what are your estrogen levels that are associated with your best function.

And that's why I think baseline testing can be so helpful.

To know where your thyroid is right now, your cortisol, your testosterone.

To know where you are with your metabolic health. So that when you're in your 40s, you can look back and say, okay, I was in a state of optimization.
I want to go back to something similar to that. So for women, what I would say is right now, 73 to 75% of women do not get the treatment for perimenopause and menopause that they deserve.
They're not being offered, for instance, hormone therapy. And that has to change.
But hormone therapy can help to reverse this so that you are more likely to not have some of these body composition changes as you get older. And it's not just hormone therapy.
I would say it's

beyond hormone therapy. It's estrogen, progesterone, testosterone, but it's also heavy weightlifting.
It's cardiovascular fitness. It's disposing of the glucose properly, eating the right foods.
Disposing of the glucose properly? Yes. What do you mean by that? So if you're, you know, like when I was in my 30s, my fasting glucose was very high.
It was in the pre-diabetes range. And so I needed to change the way that I was burning through glucose, like using it with exercise.
so disposing it an input-output equation where you're inputting with your food and you're outputting with your exercise. And you want to get a good match between the two.
And must resistance training, strength training is the optimal way to dispose of glucose, right? I think it's a critical way. I mean, what we know is strength training is it builds muscle.
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A strong body starts with strong feet. What role is fiber playing in all of this? Because a lot of people are talking about fiber at the moment and saying that we're fiber deficient.
Oh, we are for sure. I mean, the average American gets somewhere around 14 grams of fiber a day, and we're meant to have about 30 to 35, 40 grams a day.
Our Paleolithic ancestors got even more than that, 50 to 100 grams a day. So we are not getting enough fiber.
It's critical for blood sugar stabilization, so is protein intake. But getting fiber from real food, you know, eating sufficient vegetables.
We know from the microbiome studies that you want about 25 to 35 different species of fruits and vegetables in a week to be able to feed your microbiome.

And what role is the microbiome playing in my hormone function?

It's playing a huge role.

So your microbiome is one of the control functions for estrogen levels and maybe testosterone levels.

So there's a bidirectional relationship, Steve, where there are three bacteria in the gut that can take estrogen and make it keep recirculating. So you're meant to produce estrogen and then use it and then either poop or pee it out.
But what happens with some people if they've got these bacteria is they keep recirculating the estrogen like bad karma. And so those people tend to have higher estrogen levels.
It tends to be associated in men with this greater risk of metabolic dysfunction, prostate cancer. And in women, it's associated with more breast cancer and endometrial cancer.
And a lot of that starts and is caused by the gut microbiome. Yes.
And the microbiome, their favorite food is fiber. So the way that you keep your microbiome, your microbes happy and healthy is to feed them a fair amount of fiber.
What kind of foods have high fiber? Is it like broccoli and stuff? Yes. So broccoli, Brussels sprouts, cauliflower, cabbage, kohlrabi.
what do you eat and And like, how do you live? So I'm a sensualist. So I love food.
I love the taste of food. I love the smell of food.
I love the look of food. I had a history of disordered eating.
I had anorexia as a teenager and bulimia through my twenties and thirties. But now I have a more neutral relationship with food.
I have worn a continuous glucose monitor almost continuously for the past seven years. And so I know a lot about the foods that serve me the best.
So usually for breakfast, I love eggs. And so I eat fresh eggs, usually scrambled or lightly boiled.
I like to have that with greens or some other leftover vegetable from the night before. I eat a lot of vegetables.
I aim for somewhere around a half pound to a pound a day.

So that's divided between salads, the vegetables I have at dinner, a smoothie. I put vegetables in smoothies along with a protein powder.
I eat a lot of cruciferous vegetables. I have sluggish detox pathways.
I know that genomically and I know it from my biomarker testing. What does that mean? It means that maybe it's related to my sensitivity.
I don't make sufficient glutathione, which is one of the ways that you detoxify.

It's an antioxidant in your body.

And so I like to close that gap by making sure that I'm getting sufficient cruciferous vegetables. I eat a lot of broccoli sprouts.
What do you think of the keto diet? I'm a fan of the ketogenic diet. Because in your book, there's this chapter called The Keto Paradox.
Yes. What are your thoughts on keto? Well, what I find with keto is that men tend to do better on it than women.
And what I found with women is that maybe related to hormones and their sensitivity, they have more thyroid dysfunction. They have more menstrual irregularity, somewhere around 45% of women that are on a classic ketogenic diet.
So women tend to have more issues with the ketogenic diet. It takes them longer to get into ketosis than it does a man.
Even if you, the average man, if they fast for somewhere around 14 to 16 hours, they start to produce ketones. And for women, it takes longer.
It takes more like 18 to 20 hours. So probably that's related to fertility and evolutionarily, there's some pressure for us to not go into a ketogenic state, but it makes it harder for women to get into ketosis and stay in ketosis.
Is there a danger to women doing ketosis? Because you said their periods are going to become irregular. Not necessarily.
I think depending on how you do it. You know, a lot of the data that we have on the ketogenic diet is in populations that don't apply to you or me.
Because the bulk of the data that we have is in people with seizure disorders. So they're different.
It's a different population. And they're also on a form of the ketogenic diet that is very strict.
You know, no more than 10 to 20 grams of carbohydrates a day. So I think you can play with your carbohydrates and find out what your carb threshold is so that you can remain in ketosis, get the benefits of all the phytonutrients that you can get from vegetables, and play both sides so that you get the health benefits, you get the metabolic function improvement, you get the lowering of insulin without some of the side effects.
What are the side effects? The main ones that I see are the thyroid dysfunction. Sometimes there's a rise in cortisol in people who are really limiting their carbohydrates.
And then it can also affect serotonin so that people don't sleep as well on a ketogenic diet. Now, some people love that.
They go on a ketogenic diet and they're like, oh, I only need to sleep six or seven hours a night. But over time, if you need more and it's the serotonin that is at the root of why you're not sleeping as well, that can cause a problem.
Is there anything else that the ketogenic diet might be doing to my hormones, like my testosterone or my other hormones that is worth noting? Because I'm super, you know, I'm wondering whether to stay on the ketogenic diet for a long period of time. I typically do it for a couple of weeks a year, but I'm wondering if this is something that I could do for like a year or maybe longer.
So I think if you stay on it for more than a few weeks, you want to check your biomarkers. And you just want to make sure that it agrees with the intelligence of your body.
So do some molecular profiling and see if it's a good fit. Have you seen people that stay on it for years and have good biomarkers? Yes.
Okay. And I think what's important to understand is that exercise performance sometimes can be adversely affected by the ketogenic diet.
And that might be an interesting experiment for you to do, like with your running and your 5K time. What a lot of athletes do is if they want to experiment with the ketogenic diet, say they're a cyclist and they're trying to get their weight down so that their power is up, what they tend to do before a race is they add carbs back two weeks before the race so that they're filling their glycogen stores.
And so that's another piece that you may want to be tracking is your exercise performance. If I'm trying to lose weight, is there an optimal approach to take? Because the ketogenic diet has been the fastest way I've ever discovered of losing weight quickly.
But if you're a man or woman trying to lose weight, specifically like that annoying weight, the belly fats, those kinds of things, someone comes to you and says that, what do you say to them? What I like about the ketogenic diet for weight loss, and I'm really careful about weight loss because it's problematic. And I think body shaming is a big problem.
And so I'm really careful about this. But when it comes to a ketogenic diet, what I like about it is that ketones are really satisfying.
So they increase your satiety. And I think it's much more effective than trying to limit your calories and be in a calorie deficit.
So with a ketogenic diet, usually you do a calorie deficit, but you're producing ketones, which are making you feel more satisfied. So you're not standing in front of the refrigerator wondering when the next time is that you can eat.
And what about fasting? You know, there's been a lot of talk about autophagy and doing these kind of long fasts to heal the body. What's your perspective on that? I think there's a time and a place for fasting.
I think these ways of activating some of the benevolent pathways in the body can be very good for you. So it can be good for mitochondria.
It can be good for your hormone balance. It can help you with insulin, as an example.
So you asked about someone who was wanting to lose weight and also wanting to address belly fat. I would say that's a situation where you really want to pay attention to insulin.
So fasting can get you that. So can a ketogenic diet.
Often we combine the two because you can induce ketosis faster by doing intermittent fasting together with a ketogenic diet. Is the ketogenic diet like a form of fasting? You could think of it that way.
I mean,

I would say it allows you to fast and it makes the behavior change easier. You know, the thing about fasting is there are some people who are really good at it and it doesn't raise their cortisol.
It doesn't induce a stress response. And then there are other people who get very stressed with a ketogenic diet or with fasting.
And so part of it is trying to get a sense of your own response to the food that you're eating to see, okay, what suits me the best? How do I feel the best? Where is my cognitive function at an optimal level? What helps me with brain fog? What helps me with allergies or whatever symptoms you're tracking?

You know, one of the things we know with ketones, which are produced, you know, your body, as you well know, is this, it's like a hybrid car that can flip between burning gas, which is like glucose in this analogy, or electric, which in this analogy is ketones. The thing about ketones is they're not just a satiety molecule that makes you feel satisfied.
They also have anti-inflammatory aspects inside of the body. So they're an important signaling pathway.
There's a reason why your body produces ketones. Now, do you want to do that for a year? We'd have to see.
We'd have to look at your biomarkers. You know, the normal way that your genome developed was to flip in and out of ketosis based on the food supply.
And now that food is abundant, most people are not going into ketosis. But being able to switch back and forth can be very healthy for you.
When people come to you and they're asking questions about hormones these days, you must have seen in your career a shift in interest on the subject of hormones, but also a certain area of hormonal health that people have a greater obsession with. Of all the subjects we've talked about today relating to hormones, what is it that people are most interested in right now? I would say for women, it's perimenopause.
And for anyone that doesn't know what perimenopause is, when does that begin and what is it? Typically begins between 35 and 45 for women. And it's the age at which your ovaries start to run out of ripe eggs and the mitochondria in your eggs are not working the way that they once did.
And so your ovaries are aging and that leads to changes in your hormone levels. So a lot of people think of perimenopause as mostly being a hormonal situation, a change in estrogen, progesterone, maybe testosterone.
And what I think is important to realize is it's much broader than that. It's your metabolic system.
It's the way that your brain is responding to glucose. It's your immune system.
It's a time when more women have the experience of autoimmunity and autoimmune disease. So perimenopause is this incredibly dynamic time.
There's more than 100 plus symptoms that women experience. And it makes me crazy.
I was just talking to my agent and my publisher a couple of weeks ago. They're both women in their early 40s.
And they were having symptoms, you know, some of those 100 symptoms that are characteristic of perimenopause. They went to their doctor and said, I've got these mood swings, I'm having trouble sleeping, having some night sweats.
Is this perimenopause? And the doctor said, no, you're too young. So there's a knowledge gap.
There's a research gap and a knowledge gap and a huge treatment gap for women who are in perimenopause. Most women are not getting the treatment that they need.
So what are they asking about? They're asking about, why do I feel so dysregulated? Why is it that I can't manage stress the way I once did? Why would I rather mop the floor than have sex with my husband? Why is sex painful all of a sudden? Why do I have this belly fat that appeared out of nowhere, and my usual techniques for how to deal with that aren't working? Those are some of the questions that they ask, which map to your hormones. And what is the youngest you've ever seen someone enter perimenopause? Well, I see women who have premature ovarian insufficiency, which is when you go through menopause before age 40.
So I've seen a fair amount of that, you know, probably 50 patients over the course of my career. It's relatively rare.
And then I see women who have early menopause, which is when

they stop having their periods or they have an FSH level of 25 to 30. And what's FSH? Follicle stimulating hormone.
It's one of the control hormones for your estrogen and progesterone in the body. So if that occurs, they have their final menstrual period between 40 and 45, That's considered early menopause.
So there's this really dynamic time where your hormones are wildly fluctuating, especially estrogen. Progesterone is declining.
And women have this increase in the symptoms that they experience. And no one is really tracking it carefully.
That's what needs to change. Tracking it through their blood samples.
Blood samples and connecting their symptoms to what is happening in their ovaries, in their immune system, in their metabolic system, and putting it together for them and offering them options.

You believe that many of the symptoms of menopause are avoidable?

Yes. Yes.
And by that, I mean using hormone therapy and using lifestyle medicine as early as possible to manage that transition. Because when a woman goes to a doctor now,

that doctor might say, well, you're getting older, this is what happens, or they might just completely miss it. That's right.
Or they might get started on a birth control pill. That's used a lot for women who are in barri menopause, and I don't think that's the right solution.
What do you think of birth control pills? I think if they help you avoid surgery, they can be beneficial. But I think they're way overused in our culture.
And most people who agree to a birth control pill don't receive full informed consent. They're not told that it'll raise the inflammation in your body by two to threefold.
It increases your risk of autoimmune disease, especially Crohn's disease.

It makes your control system for your hormones less flexible.

It can rob you of testosterone.

It can lower your free testosterone.

It can shrink your clitoris by up to 20%. I feel like if that was part of the informed consent, very few people would sign up for it.
But who is the birth control pill for then? You know, I used to think that it was a feminist invention, that it was a way of putting your fertility in your hands. And I went on the birth control pill when I was 16,

but I feel like there are some costs to it that a lot of teenagers and women in their 20s and 30s aren't aware of. And for me, I feel like that awareness is really critical.
So who's it for? I would say it's a simple entree into contraception, but I would much rather people use things like an IUD or condoms or some other barrier method that doesn't mess with their hormonal intelligence. How are you doing? And I realized that my time with my now ex-husband had run its course.

And we came together to create this beautiful family, but we were no longer a good fit for each other. So a big part of my spiritual work has been coming to terms with that.
and really getting clear about, okay, for the second half of my life, what is it that I want? What is my mission? How do I support that? How do I only give a whole body yes to the things that I say yes to? How do I... Whole body yes.
What does that mean? Whole body yes to the things that I say yes to.

How do I? Whole body yes. What does that mean? Whole body yes.
So this is something I learned from one of my mentors, Diana Chapman. She learned it from, I believe, Katie Hendricks, who's a therapist.
the idea is that instead of saying yes to things that you're offered purely from a cognitive place, that sounds like a good idea. Sounds like a good opportunity.
Let me do it. Instead, you check in with your whole body.
You check in with your heart. You check in with your gut.
Does this really make a difference in the world? Is this something that's going to make me jump out of bed in the morning? Is this something that is worth the time and the effort? I'm a little older than you. And so I hold these opportunities a little bit differently than I did in the past.
How long were you married for? How long were you in a relationship with your partner?

We were together for about 22 years and married for 20. How does one know that it's not right anymore after 20 odd years? Well, I would love to riff on this with you.
So I can tell you that part of the challenge in my marriage was that we had difficulty talking about difficult topics. So highly charged topics were tough for us to be able to navigate.
When we had a conflict or a fight, we didn't repair very well. There was a partial repair where you would feel good enough to keep functioning and take care of the kids and do your householder stuff, but you didn't really feel seen or like you cleaned up the pain that was there.
there was a way that I didn't feel fully understood or seen. And not that I require that from my partner, but I felt like there was a misattunement.
And I'm in a relationship now where I have those things that I'm talking about, and it's someone that I have known for 30-plus years. We were interns together at UCSF.
And I realize now that, you know, I came together with my ex-husband, and I really am so blessed by the life that we had and the family that we had. But we also had a trauma bond.
There was a way that his trauma kind of intersected with my trauma, and we hung in there for a very long time, probably longer than we should have. So how do you know? I don't know, Stephen.
I just can tell you that there was a way that our interactions was creating dysregulation in my body. And I'm not blaming him.
I, you know, there's two sides to the street.

But there was a way that we just, we didn't quite gel together.

And is that not something that can be prepared through communication and therapy or sitting down?

I mean, you would hope so.

But we spent about 10 years out of the 20 years of marriage in couples therapy.

And it didn't really resolve some of these conflicts. We got better at I statements.
We got better at saying what we were feeling and not blaming. We got better at going for a walk when we were talking about something difficult.
But there was still a way that I felt alone and lonely inside of the relationship. And I decided, I think a fair number of women decide this, I decided I was better off alone than to continue in the marriage.
When people hear that, that wine in your situation, they might think, okay, so maybe he was preoccupied with something else or he worked away. When you say the word lonely, these are the kind of things we think we think of proximity.
But you're saying it, I'm guessing it wasn't proximity. It wasn't proximity.

I think it was, there was a way that we had a hard time expressing love and feeling and receiving love. There was an obstacle.
And some of it was trauma. and the good news is there's a lot you can do to resolve trauma.
But there was a way that I got to the point where I couldn't try any longer. I tried for a lot of years.
and I just couldn't keep trying.

When you look back, is there something that could have been done farther upstream to prevent you getting to this place, in your view?

Yeah, it's such a great question.

You know, one of the things that I've seen that has helped to resolve trauma

better than anything else is psychedelic-assisted therapy. It's a way of looking at your story, a way of looking at the facts of your life with more objectivity.
And it's a way of resolving the way that trauma becomes embedded in your system. And so I started doing

psychedelic-assisted therapy about five years ago with the hope that it would help me with my marriage. And what I had hoped over time is that I would do my part to resolve the trauma signature in my own body and that maybe we would do psychedelic medicine together as a way of reconnecting to the love that we felt for each other and, you know, kind of get the noise, turn down the volume on the noise.
And we weren't able to do that. He wasn't willing to.
He wasn't willing. He wasn't open to psychedelics.
And not everyone is. I'm not blaming him for that.
And I think there's other ways to create healing states of consciousness. You know, breath work can do it.
A near-death experience, peak experiences can do it. Flow states.
There's lots of different ways to create these healing states of consciousness, but we weren't able to get into that healing state together. Just for a second, I want to talk about a company I've invested in and who sponsored this podcast called Zoe.
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That's Zoe.com with code Bartlett10. One of the things I've been told by one of the menopause experts that you mentioned earlier, Lisa, was that when women get to a menopausal age, when they're in menopause, they often have greater clarity in what they want in their life.
That's what she said to me. And she said that we see divorce rates increase during this period of life.
Is that true? It is true. It is true.
Yeah. The way it was explained to me by one of my mentors was that when you're in your reproductive years, so pre-menopause, you've got a different level of estrogen, progesterone, and testosterone every day.
And it makes you accommodate, makes you kind of roll with the punches, and it sets up this level of flexibility that starts to disappear when you go through perimenopause and menopause. And so the way my mentor described it was that the hormonal veil is lifted and you start to speak your truth and not accommodate.
You speak your truth maybe for the first time

about the state of your marriage,

about the things that you're happy about,

the things that you're not happy about.

And it does lead to an increased rate of divorce.

What about your happiness levels?

Does it increase your happiness levels?

I think it does.

There's this really interesting study

that is called the U-Bend.

And it looks at psychological well-being

Thank you. And then it goes back up right around 50.
So psychological well-being goes down. I know you're 32, so I'm a little sorry to break the news to you.
And then it goes back up right around 50. So psychological well-being goes up again.
And when I first heard about this U-Bend, I remember reading an article in The Economist about it. It was so validating because it made me feel like, oh, things are really hard.
It makes sense to me that we see this through your 30s and 40s, and then it starts to have this uptick again. And I think there are ways to improve your psychological well-being so that you're not stuck in the U-bend.
But happiness, yes, I would say happiness, psychological well-being is high again in your 50s. I know that there's so many women that listen to this show.
And I get so many messages when we have conversations about women's health, hormonal issues, menopause, because women for a long period of time haven't felt like they've been heard and understood. They often feel like they're being gaslit a little bit, maybe by their doctors or by some of the information out there.
So this is quite atypical of me, but you know women better than I do. And you know what women are concerned about in all seasons of their life, what they're worried about, what they're confused about.
So I want to just open the floor to you and ask you, based on all of the work that you've done, you know,

you've done work on women's hormones, diets, lifestyle, sex drives, reclaiming their balance,

sleep, healthy weight, for both men and women, but I'm asking specifically for women here.

So with all of that in mind, what is the question that I should be asking you?

How do we do a better job supporting women? How do we do a better job supporting women? Yes, how do we do it systemically? How do we do it in terms of health care for women? But I would say, in particular for you, with the platform that you have, the women's health gap that we're facing right now,

which has only gotten worse over the 30 years of my career,

I think to ask, how do we help women rise?

How do we make systemic changes so that we don't have this women's health gap?

Let's close the gap. How do we do that together? I have a question for you.
Can you guess what the question is? I have an idea. Go on, then.
So the women's health gap, I believe, is rooted in two things. Sex differences, you know, having two X chromosomes versus X, Y, in men.
Hormonal differences, these life cycle changes that women go through, like postpartum, pregnancy, perimenopause, menopause. But then there's also gender differences, which are socially constructed.
And that includes women having more than their share of emotional labor, women having more stress than men, experiencing more stress, women having more trauma, so they have higher ACE scores than men. and it's led to, if we just look at the statistics,

double the rate of depression, double the rate of PTSD, post-traumatic stress disorder, double the rate of insomnia, four times the rate of autoimmune disease, nine times the rate of thyroid dysfunction. So there's sex differences that map to those outcomes, but then there's these gender differences.
And the way that women don't feel supported, the way that they feel conflicted in trying to create work-life balance, the way that they experience more stress, that's what we need to address. We can't change the biology, but we can change the gender differences.
We can change the socially constructed differences that lead to it being a health hazard to be female. Okay, so tell me about that then.
What is it about the socially constructed narrative of what it is to be a man and a woman that is causing unfavorable outcomes for women? There's a lot of things. So I would say what we know if you look at the nervous system, we know that women tend to have more imbalance between the sympathetic nervous system and the parasympathetic nervous system.
What's that? So the sympathetic nervous system is fight, flight, freeze. The parasympathetic nervous system is rest and digest, feed and breed, stay and play.
Is relaxed, chill, play. Relaxed, chill, that's where the healing happens.
And we're not meant to hang out in one or the other. We're meant to have this fluid balance between the two, ideally like a 50-50 split.
And so women tend to, in dealing with our culture, have more sympathetic activation. And so finding ways to address that.
More stress. More stress.
So at least in the US, we do these annual stress reports and we find that on average, women have about 10% more stress than men. Why? Is that just because they're more likely to report it? Or is there a biological or evolutionary reason why they're more stressed? I don't think it's biological.
I think it's related to power imbalances. I think it's related to patriarchy.
I think it's related to power over. So, for instance, with these ACE scores.
The trauma scores, we know that women experience more trauma than men, about 10% more similar to stress. And they also experience trauma at an earlier age compared to men.
They have much more sexual violence. They're 14 times more likely to be raped than a man.
So there are ways that our culture has allowed women to be violated. And that has to end.
How do we do that? I don't know. This is where we need to riff and figure out how do the systems change so that there's a more equal distribution of power.
Are women more sensitive? So if you put a man and a woman or a boy and a girl in the same stressful environment, would they have different biological markers, like biomarkers? Would you see high levels of cortisol in the woman

or higher cortisol levels in the man? I don't know the answer to that. My sense is from the work of Elaine Aron, who's done the work on this profile of high sensitivity, that it's about equal in men and women, but I don't know that for sure.
I'd have to fact check that. Do you see higher rates of autoimmune

diseases in women or men? Women. 4X.
4X? Yes. 400% more autoimmune diseases in women.
Yes.

And what are these autoimmune diseases? What's an example of one?

So there's about 100 autoimmune diseases. It includes things like rheumatoid arthritis,

multiple sclerosis, type 1 diabetes, Hashimoto's thyroiditis, which is the leading cause of low thyroid function, psoriasis. There's a long list.
And why are women getting these autoimmune diseases 400% more than men? We don't know. So the speculation is that it's related to both biological differences, sex differences, as well as gender differences.
So the biological differences include the difference in the levels of hormones, the X chromosome. Women have more, for instance, vaccine response compared to men.
Our immune system is more reactive in some ways than the immune system of men.

But then there's also these gender differences, these socially constructed differences, like women who have a hard time saying no, women who give until they drop, who over-function, who are trained when they go through their childhood to take care of others at the expense of their own self-care. And so how these interact and lead to a fourfold increased risk in women, we don't entirely know.
But definitely we see four times the rate in women. What's your view? There's a big debate that's always raging on about gender roles in society.
And there's obviously been a big shift over the last couple of decades in, I think, actually in part caused by the introduction of the contraceptive pill, which has meant that women are working more, I think, in the Western world, and these numbers might be wrong, there's less babies being born. Men and women are having less sex with each other.
Men are killing themselves more often. Women are coming into puberty earlier, I believe, or is it later? It's earlier.
And then having less children and significantly later. Funnily, I saw a graph yesterday which showed the rise in breast cancer amongst women.
And actually, I think it was actually, no, it was the rise in all cancers amongst women versus men. And the men graph was pretty flat, but there was this significant rise in women getting more and more forms of cancer.
And I was looking through some of the research as to why that would happen. And one of them, one of the points of research said that because women are having children later, that this is causing a rise in cancer.
Does that make sense? Well, that has been studied with, for instance, breast cancer. Okay.
So we know, you know, there's a lot of different factors that can increase a woman's risk of breast cancer. One of them is the age at which you have your first baby.
And so the way that we think of this is that it's related to estrogen exposure. So women who get pregnant and maybe they breastfeed for a year, that's often a period of time, like a year and nine months, where they're not exposed to as much estrogen than they would be if they were menstruating during that time.
And so having babies later seems to be associated with a greater risk of breast cancer. The ideal age I was taught when I went through my training for having a baby is 24.
And I don't have a single friend who's had a baby in their 20s. Is there something we're getting wrong with gender roles when you think about our biology and our hormones? I really love the questions.
I mean, they're thought experiments. So yes, I do think there's something we're getting wrong.
You had a guest recently who was talking about sex ban. Oh, yeah.
And the period of time that you're sexually active and satisfied with sex. And I do feel like we've got an epidemic of sexless marriage, people who are not having as much sex, who don't realize how important pleasure is, especially for the nervous system and for regulation.
Orgasm is one of the most effective strategies for creating nervous system regulation. For dropping into your parasympathetic nervous system.
For dropping into your parasympathetic. And what we know is that with gender roles and with what's happened with work, we've lost some of the polarity between men and women.
I mean, I imagine you also have listeners who are gay men or lesbian couples, so I want to be mindful of being inclusive here. But I think we've lost a lot of polarity.
And polarity exists in all kinds of relationships as well, doesn't it, to some degree? It does, but sometimes you have to work at it. Sometimes you have to create the polarity.
When you say polarity, if we're talking about heterosexual relationships, what is the polarity that you think we've lost? I would say right now in my 50s, I'm having the best sex of my life, the best orgasms of my life. And there's a lot of polarity in my relationship.
And I've learned that this is pretty controversial and edgy, so I'm just going to say it anyway. I feel like for women who are professionals, who work really hard, there are some ways that polarity can be really helpful in the bedroom.
And here I'm talking about gender roles and, you know, understanding sort of what, what is satisfying for you sexually and asking for it in your relationship. A lot of the professional women that I know, they enjoy vanilla sex, but they also like a weave of domination.
To be dominated or to dominate? Both. I mean, it's a personal preference, but I think there's a way that it's a way of playing with power that I think can be sexually very satisfying.
What do you think? Do you think it's important in sexual relationships to have polarity, to have like the feminine and masculine attributes? Or do you think you both just come to a sexual connection equals and that's how it should always be? I think probably the answer is that everybody has their own favorite flavor of ice cream. And I can only speak to my favourite flavour of ice cream, which is I like, I don't like vanilla ice cream.
It's not my favorite flavor. And I think I do like to be more dominant.
That turns me on. And I like to vary it because I'll get bored.
Especially if you're in a long relationship, you've got to fucking find some way to spice it up. Yes, you do.
I'm buying all kinds of stuff off the internet to try and, you know, keep it novel and new. Okay, now things are getting interesting.
Are we? Yes. Well, honestly, I've landed here in LA and before I even landed, I ordered loads of stuff just to be at the house when I got here.
Fantastic. That's what I'm like.
It's funny because my team are listening. But I go, fuck.
No, but I do because i'm like i have i have to i like try and plan sex to be interesting yes which is it's like a part-time job it is because what's the alternative the alternative is it just fizzles out and gets boring and then it's the same and um but also i think i play with distance because of the way my schedule is so i don't see my partner for a couple of weeks and then we see each other and then we go away again and so it kind of keeps it a little bit more novel and stuff and interesting i try and make sure that i stay attractive i told i said part of the reason i go to the gym every day is because we signed a contract not a real contract but we signed the contract when we met each other

that we'd stay attractive. And that's intellectually attractive.
That's physically

attractive. It's whatever.
So yeah, I think a lot about it. That's fantastic.
It's a good strategy.

And I appreciate how you are being very intentional about your sex life.

Is this in part why you knew the old relationship wasn't working? Yes. Just fizzled? It fizzled.
And I'm a very sexual person. Eroticism really matters to me.
And to not have that be front and center, felt like a death.

And you tried to revive, keep alive. Yes, yes.
People can relate. I know this because I see much of the feedback I get on the episodes where we talk about sex.
People often are struggling with a dying, whimpering sex life.

Again, I ask you, is there anything that can be done?

Is it prevention?

Is that the key here?

Or is it about making sure you're in a relationship with someone who's sexually open-minded?

And I also, I guess the third question here would be,

was it ever good?

So let me feel a way into answering your questions.

I feel like I'm going would be was it ever good so let me feel a way into answering your questions I feel like there's there's some sex differences too um biological differences between what the male sexual response and the female sexual response and that needs to understood. I feel like when you have sexual dysfunction in a relationship, it's a couple's issue.
It's never one person or the other. It's a couple's issue that you want to address as a couple.
What we know is that men are a little simpler. There tends to be desire, this physiological change that occurs in terms of blood flow and erection.
And then there's a plateau phase and then orgasm, ejaculation. We can talk about separating ejaculation from orgasm in a minute.
But in women, it's more complicated. So that was the Masterson-Johnson way of thinking about the sexual response.
Masterson-Johnson. Masterson-Johnson.
And now we know... What's that, sorry? Masterson-Johnson, they were sexologists that published this particular model.
Yeah. And it wasn't until maybe 15, 20 years ago

that Rosemary Besson at the University of British Columbia

found that women have a different response.

It's more circular.

And it has to do with feeling emotionally connected

in order to be receptive to having sex with their partner. Whereas

men in some ways do the opposite. And I'm curious if this is true for you.
They need to have sex

in order to feel emotionally connected. Women actually need the emotional connection first

to be receptive to sexuality.

And so this leads to a lot of disconnect.

And it includes things like, how many times in the past week did you empty the dishwasher? There are things that create emotional connection that a lot of men don't realize. And then for women, they often don't feel like the sexual response will not happen unless they feel emotionally connected.
And this was part of the problem in my own marriage was that I didn't feel that emotional connection. I tried really hard to establish that emotional connection, but I didn't have it.
I have it now. Is it related to the newness of my relationship? Maybe.
And knowing that, knowing about the emotional connection, in some ways changes your homework as a man. Do you know what makes your girlfriend feel emotionally connected? Quality time, deep questions.
Yes. The conversation cards.
Oh, yes. Tell me about that.
Well, we sell these conversation cards on this show. You can check in the description below if you want to buy them.
But basically, at the end of the conversations on this podcast, the guests write a question in this diary in front of me for the next guest. And then these will become conversation cards.
Unlock deeper levels of connection, open up to to open up level three is the more deep questions oh i like it um this is probably a level three person you're a level three person i would imagine you strike me as a level three person you really do but those kinds of things so like deep um deep questions and spending time and then that. Can I see some of those level threes?

Yeah, here are all your level threes.

What is the most important thing we haven't talked about that we should have talked about?

Is there anything else?

Sleep is something we didn't talk about.

When we think about the impact sleep has on our hormonal balance, is it important?

Oh my gosh.

Sleep is as close to a panacea as we have.

When you say panacea, you mean like the Holy Grail?

It is the Holy Grail. It is so critical for functioning.
You know, what I see taking care of a lot of executives is that they think that they're the exception, that they don't need 70.5 hours of sleep every night. But only about 2% of the population has the short sleep gene.
The rest of us need to optimize our sleep to the best of our ability. So what we know is that it affects your hormones inside of 24 hours.
One bad night of sleep raises your insulin, raises your cortisol the next day, makes you more hungry, makes you more likely to crave carbohydrates. So just like you can create a negative cycle, you can create a positive cycle by optimizing your sleep.
I'm a big fan of wearables because especially if you wake up in the morning and you don't feel flush with sleep and fully restored and fully recovered, you want to understand the metrics. How much deep sleep did you get? How much REM sleep? How many interruptions did you have? Did you snore? What was your heart rate variability? What was your respiratory rate? So I feel like sleep is one of those lifestyle factors that we need to optimize.
On my ketogenic diet, I noticed that my heart rate variability seems to go lower, which is scary. Do you see that a lot when people do kind of these kind of more restrictive diets and they're in ketosis? There can be.
I mean, I would look at some of the other variables as well. And one of the things I really like is the eight sleep.
Have you used that at all? Yeah, I have. The mattress.
Did it help you with HRV? I believe it did. I had the results at the time, but I was sleeping really, really good on it.
I still use my whoop,, which hashtag ad. I still use my WHOOP for my HRV.
What are the things that you aim at when someone comes to you with low HRV? A lot of people want to improve their HRV. You kind of see it as this holy metric now.
Sure. Well, I start with alcohol.
So we know alcohol makes your HRV decline, not just for one night, but somewhere around seven to nine nights. That's why I quit alcohol.
Yes. My HRV just killed my, the first time I put my whoop on and I saw the impact it had on my HRV, I thought, I'm not doing that again.
And that's exactly the kind of behavior change that I get excited about. So when you see the metrics and you see the reflection of, oh my gosh, my physiology is so much better off of alcohol, and there's better choices than alcohol, you want to make that swap.
And the behavior change sticks. So I like grounding.
So I find when I get in the ocean, when I get in streams with bare feet, when I walk on the sand, that improves my HRV. The country that seems to improve my HRV the most is Costa Rica.
There's something about the aliveness there. My HRV doubles to triples.
Microdosing mushrooms also raises my HRV quite significantly. We have a closing tradition on this podcast, like I said, where the last guest leaves a question for the next guest,

not knowing who they're leaving it for.

And the question left for you is,

what do you do every day to make a better brain and better world?

What I do every day when I'm home in Marin County is I go outside when I wake up in the morning. And I look at the, I live on the ocean and I look at the horizon, like I trace my eyes along the horizon.
And I just was looking at the data on morning sun because I didn't quite believe it. Supposedly, it helps you with your circadian rhythm.
It helps you with sleeping better. It helps you with melatonin production.
It helps you with mood. It's got all of these benefits, and some people say, you only need five or 10 minutes of morning sun.
That's sufficient. And so I started looking at the data, and you actually need more than that.
Like you start to see a benefit around 30 minutes, but you need, you still keep improving some of these outcomes with longer, like up to two and a half hours. So the thing I do every day is I get morning light and I trace the horizon and I look at nature and I remind myself that nature is the best way to regulate.
That helps my brain. Sarah, thank you.
Thank you so much for doing the work that you do. You're an incredibly intriguing person in many respects, and you're clearly helping so many people in so many wonderfully important ways.
I highly recommend everybody go and check out the books that I have in front of me. There's quite a few of them.
I think there's six in total. I've got three here.
The Autoimmune Pure, Healing the Traumas and Other Triggers That Have Turned Your Body Against You is the book that I'm going to highly recommend. I think this is the new one.
And I've interviewed Paul Conte, who writes the recommendation for the book on the back of this. I've also got another book here called The Hormone Cure, which is all about reclaiming balance, sleep and sex drive, maintaining a healthy weight, feeling focused, vital and energized naturally.
And one of the books that I was referencing as we were going, which is Woman, Food, and Hormones, a four-week plan to achieve hormonal balance, lose weight, and feel like yourself again. If people want to know more from you, they want to hear you, you have a new podcast, right? Yes.
Where do you go to listen to your podcast? My website is sarahzallmd.com and the podcast is called Treated with Dr. Sarah.
That's Sarah Zal spelt S-Z-A-L. That's right.
And the podcast is called Treated with Dr. Sarah.
Thank you so much. Thank you so much, Stephen.
We launched these conversation cards and they sold out and we launched them again and they sold out again. We launched them again and they sold out again because people love playing these with colleagues at work, with friends at home and also with family and we've also got a big audience that use them as journal prompts.
Every single time a guest comes on the diary of a CEO they leave a question for the next guest in the diary and I've sat here with some of the most incredible people in the world and they've left all of these questions in the diary and I've ranked them from one to three in terms of the depth. One being a starter question and level three, if you look on the back here, this is a level three, becomes a much deeper question that builds even more connection.
If you turn the cards over and you scan that QR code, you can see who answered the card and watch the video of them answering it in real time. So if you would like to get your hands on some of these conversation cards, go to thediary.com or look at the link in the description below.
I find it incredibly fascinating that when we look at the back end of Spotify and Apple and our audio channels, the majority of people that watch this podcast haven't yet hit the follow button or the subscribe button, wherever you're listening to this. I would like to make a deal with you.
If you you could do me a huge favor and hit that subscribe button I will work tirelessly from now until forever to make the show better and better and better and better I can't

tell you how much it helps when you hit that subscribe button the show gets bigger which

means we can expand the production bring in all the guests you want to see and continue to doing

this thing we love if you could do me that small favor and hit the follow button wherever you're

listening to this that would mean the world to me that is the only favor

i will ever ask you thank you so much for your time Thank you.